Commercial Auto Quote

Bus Owner(s) Name*

Business Name*

Type of Business *
Sole OwnerPartnershipLLCIncorporationN/A

Phone*

Email:*

GARAGING ADDRESS:*

NO. OF YEARS IN BUSINESS (With own insurance):*

FEIN #:*

COMMODITIES HAULED(Be Specific about percent of Time):*

FILLING REQUIRED*
NoneICCDMVOtherN/A

RADIUS:*
Intrastate (CA only)0-100 MILES101-200 MILES201-300 MILES301-500 MILESIntrastate-Exactly where?N/A

Driver Information
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Driver(D1)*

Drivers License #(D1)*

State of Issue(D1)*

Type CDL*
ABCN/A

Endorsement*
Air BrakesHaz MatTankerTandemN/A

YRS EXP D1*

ACCIDENTS D1*

Driver(D2)

Drivers License #(D2)

State of Issue(D2)

Type CDL
ABCN/A

Endorsement
Air BrakesHaz MatTankerTandemN/A

YRS EXP D2

ACCIDENTS D2

Driver(D3)

Drivers License #(D3)

State of Issue(D3)

Type CDL
ABCN/A

Endorsement
Air BrakesHaz MatTankerTandemN/A

YRS EXP D3

ACCI. D3

Driver (D4)

Drivers License #(D4)

State of Issue(D4)

Type CDL
ABCN/A

Endorsement
Air BrakesHaz MatTankerTandemN/A

YRS EXP D4

ACCI. D4

*Specify the number of year’s commercial driving experience each driver has. If there are any drivers with a “not at fault” accident, please provide a copy of the policy report with your submission

Vehicle / Equipment:
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Vehicle / Equipment 1
​

Year E1*

Make E1*

Model E1*

Vin # E1*

SAA E1*

Vehicle / Equipment 2
​

Year E2

Make E2

Model E2

Vin # E2

SAA E2

Vehicle / Equipment 3
​

Year E3

Make E3

Model E3

Vin # E3

SAA E3

Vehicle / Equipment 4
​

Year E4

Make E4

Model E4

Vin # E4

SAA E4

*If there are 5 or more power units, please provide a completed ACORD or completed company application instead of this form for quoting.

TRAILER(S):
​

TRAILER(T1)
​

Year

Make

Body Type

GVW

Stated Value

Deductible

*Please specify if applicant is pulling non-owned trailers and if applicant is pulling doubles.

COVERAGES:

AUTO LIABILITY:
$100K CSL$300K CSL$500K CSL$750K CSL$1M CSL$500AUTO LIABILITY DEDUCTIBLE:OTHERN/A

UNINSURED MOTORIST BI
$15,000/$30,000$25,000/$50,000$30,000/$60,000CARGO$25,000$50,000DEDUCTIBLEN/A

OTHER COVERAGE
DEDUCTIBLE:

PRIOR INSURANCE HISTORY FOR THE PAST 3 YEARS:

POLICY PERIOD
​

(MM/YY)

COMPANY NAME

LIABILITY LOSSES
​

NUMBER

AMOUNT

LOSSES
​

NUMBER

AMOUNT

*If any prior losses, please provide a copy of currently valued loss runs.
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